Wiki Billing secondary insurance when OON with primary

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If a provider is not in network with a patient's primary insurance, can that provider refuse to file claim to an in network or contracting secondary insurance?
 
If a provider is not in network with a patient's primary insurance, can that provider refuse to file claim to an in network or contracting secondary insurance?

I would initially file with the primary and then whatever is denied send it to the 2ndary. I think it's up to office policy if you file to 2ndary insurances.
 
I would initially file with the primary and then whatever is denied send it to the 2ndary. I think it's up to office policy if you file to 2ndary insurances.
So more specifically...
Say I am out of network with patient's primary insurance and they have no secondary. Primary pays a portion and I balance bill the patient for the remaining amount.

However, say I am out of network with patient's primary insurance and they have Medicaid as secondary (which I am in network with). Can I refuse to send their claim to Medicaid given the fact that I am not in network with their primary insurance...even though I am in network with their secondary?
 
So more specifically...
Say I am out of network with patient's primary insurance and they have no secondary. Primary pays a portion and I balance bill the patient for the remaining amount.

However, say I am out of network with patient's primary insurance and they have Medicaid as secondary (which I am in network with). Can I refuse to send their claim to Medicaid given the fact that I am not in network with their primary insurance...even though I am in network with their secondary?

I think it is unlikely that this would be allowed. You may want to look at your participation agreement with Medicaid and/or your Medicaid provider handbook for a definitive answer, but these will usually require you to file the claim with them, whether they are the patient's primary or secondary payer. I most cases, the only you can bill a Medicaid patient is when you are providing a service that you know is not covered by the Medicaid plan and you have notified the patient in advance that this is the case, but look to your state's Medicaid rules for a definitive answer on this.

And even if you are out of network with the primary payer, you'll need to file the claim with them for the primary payer's benefit determination, because the Medicaid plan will not be able to coordinate benefits without that information. Some payers do allow patients to go out of network and may pay a portion of the charges, in which case Medicaid may make up the difference, or may determine that the amount already paid constitutes payment in full under the terms of your Medicaid program.
 
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So more specifically...
Say I am out of network with patient's primary insurance and they have no secondary. Primary pays a portion and I balance bill the patient for the remaining amount.

However, say I am out of network with patient's primary insurance and they have Medicaid as secondary (which I am in network with). Can I refuse to send their claim to Medicaid given the fact that I am not in network with their primary insurance...even though I am in network with their secondary?


No. If the patient has Medicaid secondary, you need to bill Medicaid. It would be a compliance issue if you didn't.
 
I think it is unlikely that this would be allowed. You may want to look at your participation agreement with Medicaid and/or your Medicaid provider handbook for a definitive answer, but these will usually require you to file the claim with them, whether they are the patient's primary or secondary payer. I most cases, the only you can bill a Medicaid patient is when you are providing a service that you know is not covered by the Medicaid plan and you have notified the patient in advance that this is the case, but look to your state's Medicaid rules for a definitive answer on this.

And even if you are out of network with the primary payer, you'll need to file the claim with them for the primary payer's benefit determination, because the Medicaid plan will not be able to coordinate benefits without that information. Some payers do allow patients to go out of network and may pay a portion of the charges, in which case Medicaid may make up the difference, or may determine that the amount already paid constitutes payment in full under the terms of your Medicaid program.
Thank you! This is exactly what I thought.
 
If a provider is in network with primary insurance such as Medicare, they pay their 80% then the 20% is submitted to secondary and they state that is ineligible due provider out of network can we bill the patient the remainder.
 
If a provider is in network with primary insurance such as Medicare, they pay their 80% then the 20% is submitted to secondary and they state that is ineligible due provider out of network can we bill the patient the remainder.
If secondary does not cover the MCR co-insurance due to non-participation, you may bill the patient for the 20% assuming you properly informed the patient about being out of network.
 
If secondary does not cover the MCR co-insurance due to non-participation, you may bill the patient for the 20% assuming you properly informed the patient about being out of network.
Hello, do you have a link to show we can balance bill the patient if we are out of network with Medicaid?
 
If a provider is in network with primary insurance such as Medicare, they pay their 80% then the 20% is submitted to secondary and they state that is ineligible due provider out of network can we bill the patient the remainder.
Hello fmshero1, do you by chance have a link to show we can balance bill the patient if we are out of network with Medicaid?
 
Hello, do you have a link to show we can balance bill the patient if we are out of network with Medicaid?
Different states have different requirements regarding out of network Medicaid. If allowed, the EOB would indicate patient responsibility.
 
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